Surgical management of advanced gastric cancer: An evolving issue.

Worldwide, gastric cancer represents the fifth most common cancer and the third leading cause of cancer deaths. Although the overall 5-year survival for resectable disease was more than 70% in Japan due to the implementation of screening programs resulting in detection of disease at earlier stages, in Western countries more than two thirds of gastric cancers are usually diagnosed in advanced stages reporting a 5-year survival rate of only 25.7%. Anyway surgical resection with extended lymph node dissection remains the only curative therapy for non-metastatic advanced gastric cancer, while neoadjuvant and adjuvant chemotherapies can improve the outcomes aimed at the reduction of recurrence and extension of survival. High-quality research and advances in technologies have contributed to well define the oncological outcomes and have stimulated many clinical studies testing multimodality managements in the advanced disease setting. This review article aims to outline and discuss open issues in current surgical management of advanced gastric cancer.

Multiple primary malignancies. A rare case of five metachronous tumours.

The Authors report on a patient admitted several times for the occurrence of five multiple metachronous primary malignancies (laryngeal carcinoma, endometrial adenocarcinoma, rectal cancerous polyp, Vaterpapilla carcinoma and transverse colon cancer). All five carcinomas were independent primary cancers and the lenghty time intervals between the onsets of each individual tumours confirm their independent non-metastatic origin. Classification, pathogenesis, genetic and environmental interactions of these tumours are discussed; in the case reported a family history of colon cancer was present, while no genetic markers abnormalities or chronic exposure to carcinogens were found. The case report suggests that an aggressive, appropriate surgical approach together with a through follow-up monitoring offers a chance of long-term survival for patients with metachronous malignant primary tumours.

[The abdominal wall: an overlooked cause of pain]. / La parete addominale: una trascurata fonte di dolore.

Abdominal wall pain is frequently misdiagnosed as arising from visceral source, often resulting in inappropriate diagnostic tests, unsatisfactory treatment and high costs. The Authors describe the various causes of abdominal wall pain with particular regard to abdominal cutaneous nerve entrapment syndrome. They analyze the main features of abdominal wall pain: a localized tender trigger point can be frequentely identified, the Carnett's sign is positive and the local injection of an anesthetic agent into the trigger point can be diagnostic and therapeutic, while image techniques are useful when the pain results from structural conditions. At last they describe the therapeutic options.

[Gastric diverticulum. A case report with long-term follow-up and a review of the literature]. / Il diverticolo dello stomaco. Descrizione di un caso clinico con follow-up a lungo termine e revisione della letteratura.

A rare case of symptomatic gastric diverticulum surgically managed is reported. The pathogenetic and clinical aspects of the disease are discussed and the usefulness of endoscopy as a means for differentiation between medical and surgical cases is stressed. A review of the literature is made and the conclusion is drawn that this uncommon pathology is often asymptomatic and requires surgical management only in complicated cases and in symptomatic patients that are not responding to medical treatment, as showed by the long-term follow-up (333 months) of the reported case.

Comparative retrospective study on the use of plastic prostheses and self-expanding metal stents in the palliative treatment of malignant strictures of the esophagus and cardia.

Palliative treatment of malignant strictures of the esophagus and cardia is usually carried out by the endoscopic placement of a prosthesis. The aim of this retrospective study was to evaluate short- and long-term outcomes of the use of expandable stents, compared with conventional plastic prostheses. One hundred and thirteen endoscopic intubations were carried out in 120 patients affected by malignant stenosis of the esophagus and cardia using plastic prosthesis and self-expanding metal stents. Dysphagia was scored according to Atkinson and Ferguson's classification and the preoperative median score (3.6) was comparable in both groups. The technical success rate was 94.4% with plastic prosthesis and 93.7% with self-expanding metal stent while the functional success rate was, respectively, 85.2% and 88.8%. Three deaths occurred with plastic prostheses (4.4%), while no deaths were observed with metal stents. A comparative analysis of the results of this study suggests that the endoscopic placement of self-expanding metal stents is effective and safe and has to be preferred to the conventional plastic prosthesis for easier implantation and lower morbidity.

[Gastric stromal tumors. Our experience in 21 cases surgically managed]. / I tumori stromali dello stomaco. La nostra esperienza su 21 casi trattati chirurgicamente.

BACKGROUND: A retrospective review on 21 patients with gastric stromal tumors who underwent surgical treatment in the period 1974-2001, is presented. METHODS: The patients were 8 males and 13 females, with an average age of 62.6 years. Histological examination showed 15 smooth muscle tumors (9 benign and 6 malignant), 5 neural tumours (3 benign and 2 malignant) and 1 undifferentiated tumor. Main symptoms were abdominal pain and palpable abdominal mass and the most sensible diagnostic techniques were endoscopy and abdominal CT-scan. Surgical procedures performed were: local resection (15 cases), partial gastric resection (3 cases), subtotal gastrectomy (2 cases) and total gastrectomy (1 case). RESULTS: There were no operative mortality and morbidity. Among 12 patients with benign GSTs, 1 died for causes not related to the disease, while 11 patients are still alive and in good health after a mean follow-up of 148.5 months (range 6-262). Among patients with malignant muscular GSTs, 3 were lost to follow-up and 3 are alive and free from disease after a median follow-up of 58 months (range 3-108). The 2 patients with malignant neural GSTs are still alive and in good health 140 and 24 months after surgical procedure, while the patient with undifferentiated GST died for liver metastases 43 months after total gastrectomy. CONCLUSIONS: The authors conclude that the most frequent symptoms are abdominal pain and a palpable mass, but no specific signs have been detected. Endoscopy plays a very important diagnostic role and CT-scan is the most sensible technique in the evaluation of location, size, invasion of adjacent organs and metastasis. The aim of treatment must be the complete resection of the tumor and the prognostic prediction on the basis of histologic findings is quite difficult.

[Multiple primary malignant neoplasms. Report of a rare case with 5 metachronous tumors]. / Le neoplasie maligne primitive multiple. A proposito di un raro caso con cinque tumori metacroni.

The Authors report on a patient admitted several times for the occurrence of five multiple metachronous primary malignancies (laryngeal carcinoma, endometrial adenocarcinoma, rectal cancerous polyp, ampulla of Vater carcinoma and transverse colon cancer). All five carcinomas were independent primary cancers, and the lengthy time intervals between the onsets of the individual tumours supports their independent non-metastatic origin. Classification, pathogenesis, genetic and environmental interactions of multiple tumours are discussed. In the case reported, a family history of colon cancer was present, while no genetic marker abnormalities or chronic exposure to carcinogens were found. The case report shows that an aggressive, appropriate surgical approach together with thorough follow-up monitoring offers a chance of long-term survival for patients with metachronous malignant primary tumours.

[Surgical treatment of redundant colon after retrosternal esophagocolonoplasty for caustic esophageal stenosis]. / Il trattamento chirurgico della ridondanza colica dopo esofagocolonplastica retrosternale per stenosi esofagea da caustici.

The Authors report two cases of transposed colon redundancy occurring after surgical treatment in 37 patients with caustic oesophageal strictures by retrosternal oesophagoplasty. Surgical management was required because of persistent dysphagia and weight loss in both patients. The technique performed was a resection of the redundant loop with a termino-terminal colo-colonic anastomosis via a right thoracic approach.

[Pancreatic pseudocysts. Our experience with 21 cases treated surgically]. / Le pseudocisti del pancreas. La nostra esperienza su 21 casi trattati chirurgicamente.

Twenty-one consecutive patients with pancreatic pseudocyst have been reviewed. Nine cases have been treated with internal drainage, 9 with external drainage, while 3 patients have undergone distal pancreatectomy. No mortality was associated to the surgical treatment, while morbidity was of 9.5% due to pancreatic fistulas. Based on their own experience and literature review the Authors describe clinical, diagnostic and therapeutic features of the disease and point out the good results of cistojejunostomy with Roux-en-Y loop.

[Our experience in the surgical treatment of gastrointestinal stromal tumors]. / La nostra esperienza nel trattamento chirurgico dei tumori stromali gastrointestinali.

The authors carry out a retrospective review of 30 patients with gastrointestinal stromal tumours (GISTs) who underwent surgical treatment over the period from 1974 to 2001. Sixteen were male and 14 female, with an average age of 60.9 years. Histologically, 19 tumours showed evidence of differentiation towards smooth muscle elements (10 benign and 9 malignant), 9 towards neural elements (3 benign and 6 malignant) and 2 iacked differentiation towards either cell type. Twenty-one tumours were located in the stomach, 1 in the duodenum, 3 in the jejunum and 5 in the ileum. The main symptoms were abdominal pain and abdominal masses, and the most sensitive diagnostic techniques were abdominal CT scan and endoscopy in gastroduodenal locations. In 21 gastric GISTs, the surgical procedures were local resection (15 cases), partial gastric resection (3 cases), subtotal gastrectomy (2 cases) and total gastrectomy (1 case). In 8 small bowel GISTs, we performed a typical intestinal resection while duodenal undifferentiated GIST was managed by pancreatico-duodenectomy. There was no operative mortality or morbidity. Among the 13 patients with benign GISTs, 1 died of causes unrelated to the disease, while 12 patients are still alive and in good health after a mean follow-up of 148.5 months (range: 6-262). Among patients with malignant muscular GISTs (6 gastric and 3 ileal), 3 with gastric tumours were lost to follow-up, 3 with gastric and 1 with ileal neoplasms are alive and free from disease after a median follow-up of 58 months (range 3-108), while 2 patients with ileal neoplasms died of metastatic disease 39 and 29 months after the surgical procedure. Among 6 patients with malignant neural GISTs (2 gastric, 2 jejunal and 2 ileal) 1 with a gastric tumour and 1 with a jejunal tumour were lost to follow-up, while 3 are still alive and in good health after a median follow-up of 67.6 months (range 19 to 94); another with jejunal disease developed liver metastases 14 months after small bowel resection and died 12 months later. The two patients with undifferentiated GIST both died of liver metastasis 38 months after pancreatico-duodenectomy and 43 months after total gastrectomy. The most frequent symptoms were abdominal pain and a palpable mass, but no specific signs were detected. In gastroduodenal lesions endoscopy plays a very important diagnostic role and CT scan is the most sensitive diagnostic technique in the evaluation of location, size, invasion of adjacent organs and metastases. Prognostic prediction on the basis of histological findings is difficult and in our experience undifferentiated tumours are always malignant.

[Duodenal duplication. Report of 2 cases in adults and review of the literature]. / La duplicazione del duodeno. Descrizione di due casi nell'adulto e revisione della letteratura.

Two cases of adult male patients with symptomatic duodenal duplication cysts are reported. The clinical manifestations were vomiting and epigastric pain in the first case and recurrent pancreatitis with a palpable mass in the right upper quadrant of the abdomen in the second. In both cases the diagnosis was only histological and the patients recovered after local excision of the duplication and duodenopancreatectomy, respectively. These two cases prompted an evaluation of the diagnostic features and surgical treatment of duodenal duplication cysts.

[Malignant schwannoma of the small intestine: a report of 2 cases]. / Lo schwannoma maligno dell'intestino tenue: descrizione di due casi.

The authors report two cases of small bowel malignant schwannoma. It is an extremely rare disease and it is often difficult to diagnose malignancy. Histologic differentiation from other stromal tumors may require electron microscopy, although the preparation of immunohistochemical reactions now allows to identify forms which were previously diagnosed in different terms to be precisely classified. Diagnosis is often late and no preoperative test enables a correct clinical diagnosis to be made. The primary treatment is surgical and the resection is the only real therapy. Radiotherapy and chemotherapy are ineffective. Close postoperative observation is recommended because of the tendency to recurrence and metastasis.

[Stenotic endometriosis of the sigmoid. Apropos a case]. / L'endometriosi stenosante del sigma. A proposito di un caso.

The authors report a rare case of stenotic sigmoid endometriosis which presented with constipation and dysmenorrhea in a 48-year-old woman without past gynecological history. There were no typical radiological and endoscopic findings and only pathological examination revealed endometriosis. The patient did well after sigmoid resection and bilateral salpingo-oophorectomy and has had no further complaints. The authors stress the rare location of the disease and review the literature about etiopathogenetic hypotheses and pathological features. The diagnostic value of clinical examination, barium enema and colonoscopy is low as endometriosis rarely involves the mucosa. This case led the authors to discuss about diagnostic difficulties, differential diagnosis and therapeutic options.

Palliative treatment of malignant esophageal stenosis: the role of self-expanding stent endoscopic implantation.

Endoscopic tube implantations were carried out in 40 patients with malignant stenosis of the esophagus and gastric cardia using self-expanding metallic stents. The indications for endoscopic intubation were the advanced stage of the tumor in 27 cases and risk factors that made resection inadvisable in 13 cases. In three patients, it proved impossible to implant a stent endoscopically because we were not able to pass the guide wire through the stenosis, whereas correct stent placement was achieved in 37 cases. Functional results were good in 33 patients, but four patients did not show any improvement of symptoms. Complications occurred in nine patients (24.3%): two bleedings, three neoplastic obstructions, one food obstruction, and three distal dislodgements of the prosthesis were observed, but could be readily corrected. No deaths occurred. The median survival time was 151 days (range 25-545 days). This study suggests that endoscopic placement of metallic self-expanding stents is safe and is to be preferred to plastic stents for easier implantation and lower morbidity.

[Malignant stromal tumors of the duodenum. Report of a case]. / I tumori stromali maligni del duodeno. A proposito di un caso.

The Authors report a rare case of undifferentiated duodenal malignant stromal tumour in a 69-years-old man radically managed by pancreaticoduodenectomy and resection of a liver metastasis. Several preoperative tests were performed (barium meal, endoscopy, ultrasonography and CT scan) but failed to yield a differential diagnosis between a tumour of the pancreatic head and a retroperitoneal neoplasm. The diagnosis was only histological. The tumour was considered to be high-grade due to its large size, high mitotic index, and the presence of necrosis and liver metastasis. Thorough surveillance revealed several hepatic metastases 29 months after resection, and chemotherapy performed at this stage proved completely ineffective. The patient died 38 months after surgery.

[Clinical-diagnostic and therapeutic considerations in a rare case of mesenteric cyst]. / Considerazioni clinico-diagnostiche e terapeutiche su un raro caso di cisti mesenterica.

The authors report a rare case of mesenteric cyst in a 36 years old woman. These cysts have a pathogenesis that primarily may be ectopic lymphatic tissue and their most common site is in the small bowel mesentery, especially of the ileum. In the case reported the cyst was located in the right mesocolon. Mesenteric cysts can appear as chronic abdominal pain, a painless abdominal mass, or acute abdomen. Diagnostic aids include abdominal computed tomography and sonography, that usually make diagnosis of mesenteric cyst. Treatment of choice is enucleation; resection of the adjacent bowel may occasionally be necessary.

[Current trends in the surgical treatment of lesions caused by caustic ingestion]. / Attuali orientamenti sul trattamento chirurgico delle lesioni da ingestione di caustici.

During a twenty-six year period from 1973 to 1999 a total of 78 patients with severe esophago-gastric lesions after caustic ingestion were referred to and managed at our unit. Hydrochloric acid was the most frequently involved caustic agent and the lesions were located in the esophagus (52.6%), in the stomach (19.2%) and in both the esophagus and stomach (28.2%). Thirty-seven patients were managed by endoscopic dilation of esophageal stricture that gave permanent relief of dysphagia in 13 cases only. Twelve patients are still managed with endoscopic dilation and in another 12 we performed bypass surgery. Two perforations developed and spontaneously sealed after T.P.N. for 6-8 weeks. No death occurred. Fifty-three patients were operated on in emergency or during survey period or for stenotic lesions. Surgical procedures were: in esophageal strictures a substernal esophago or pharyngocologastroplasty without esophagectomy; in esophago-gastric strictures, after an esophago-gastrectomy, an esophago or pharyngocolojejunoplasty in one or two steps; in total gastric stenosis without esophageal involvement a total gastrectomy followed by a Roux-en-Y esophago-jejunal anastomosis and in antropyloric strictures a Billroth I or II partial gastrectomy. The morbidity rate was 32% with a 5.6% mortality rate.

[Hartmann's procedure in colorectal tumors. Evolutions of the indications in a series of 46 patients]. / L'intervento di Hartmann nei tumori colo-rettali. Evoluzione delle indicazioni in una serie di 46 pazienti.

The Authors report a retrospective study of 46 cases of Hartmann's operation in order to analyze the changing indications to this procedure in the management of colo-rectal cancer. The Hartmann's is operation has been performed in 46 out of 723 patients (6.4%) with colorectal cancer treated surgically from 1973 to 1997. Data concerning the indications have been analyzed in two consecutive periods, from 1973 to 1985 and from 1986 to 1997, respectively. In the first period, the procedure has been performed in patients with neoplastic perforation (40% of Hartmann's cases), and in an elective basis in patients with locally invasive tumor or intra-abdominal metastasis (20%). Indications for the procedure in the period 1986-1997 have been locally invasive tumor and/or distant metastasis (52.8% of Hartmann's procedures), neoplastic perforation (22.2%), high surgical anaesthesiologic risk (22.2%) or intestinal obstruction (2.8%). In the second period it has been noted a decrease of the number of patients that underwent Hartmann's procedure for bowel obstruction, and an increase in the number of cases in which the operation was performed for neoplastic perforation, for local and/or distant diffusion, or for high surgical risk.

[Synchronous primary carcinoma of the colon. Diagnostic and therapeutic problems]. / II carcinoma primitivo sincrono del colon. Problemi diagnostici e terapeutici.

Seven hundred and twenty-three patients with colorectal carcinoma were treated consecutively from November 1973 to April 1997. Seven patients (0.96%) were found to have two colorectal carcinomas (synchronous carcinoma), located in separated colonic areas. Clinical histories were analyzed with reference to sex, age, symptoms, physical findings, disease localization, pathologic classification, and survival data. Preoperative diagnosis of synchronous lesions is difficult, being achieved in only 2 cases, but it is important for the proper treatment of patients. It is concluded that full examination of the colon in all patients presenting with primary colorectal cancer is mandatory and that colonoscopy should be used to effectively screen patients for synchronous cancers.

[Self-expanding stents for the palliation of esophageal and gastric cardia cancer]. / L'impiego delle protesi autoespansibili nel trattamento palliativo del carcinoma dell'esofago e del cardias.

Twenty-one endoscopic tube implantations were carried out in 24 patients with malignant stenosis of esophagus and gastric cardia using self-expanding metallic stents. The indications to endoscopic intubation were advanced stage of the tumor in 17 cases and risk factors which made resection inadvisable in 7 cases. In 3 patients it proved impossible to implant a stent endoscopically because the Authors were not able to pass the guide wire through the stenosis, while correct stent placement was achieved in 21 patients. Functional results were good in 18 patients, while 3 patients did not have any improvement of symptoms. Complications occurred in 9 patients (42.85%): 2 bleedings, 3 neoplastic obstructions, 1 food obstruction and 3 distal dislodgements of the prostheses were observed, but could readily be corrected. No death occurred. The median survival time was 151 days (range 25-545). This study suggests that endoscopic placement of metallic self-expanding stents is safe and has to be preferred to plastic stents for easier implantation and lower morbidity.